Policy Manual sample

MDT Home Health Care Agency, Inc. In accordance with Centers for Disease Control recommendations and in compliance with OSHA regulations, the Agency shall provide treatment, follow-up testing, and referral for documented occupational exposure to communicable diseases from blood and/or body fluids. A. Laboratory Tests - various laboratory tests may be ordered to evaluate both the source individual (patient) and the worker (employee). These tests may include, but are not limited to: HBsAB (Hepatitis B surface antibody) - will tell if the exposed worker (employee) is protected against Hepatitis B. HBsAG (Hepatitis B surface antigen) - will tell if the source individual (patient) has Hepatitis B. HIV - used to determine the presence of the antibody or antigen to human immunodeficiency virus infection. RPR/SATS - common tests for syphilis. B. Follow-up procedure after exposure incident to HIV/HBV: A licensed physician will document in the employee's medical record that an exposure incident has occurred and that HIV testing of the source patient is medically necessary to determine the course of treatment. C. Follow-up procedures after possible exposure to HIV/HBV: If a health care worker has a percutaneous (needlestick or cut) or mucous membrane (splash to eye, nasal mucosa, or mouth) exposure to body fluids or has a cutaneous exposure to blood when the worker's skin is chapped, abraded, or otherwise non-intact, consent is attained and the source patient shall be informed of the incident and tested for HIV and HBV infections. The health care worker shall be evaluated clinically. HIV antibody testing will be done as soon as possible and the health care worker will be advised to report and seek medical evaluation of any acute febrile illness that occurs within 12 weeks after exposure. HIV seronegative workers shall be retested 6 weeks post-exposure and on a periodic basis thereafter (12 weeks and 6 months after exposure). The type of procedures followed for health care workers exposed or potentially exposed, depend on the immunization status of the worker (i.e., whether HBV vaccination has been received and antibody response is adequate) and the HBV serologic status of the source patient. No adverse action by the employer can be taken if a health care worker refuses to submit to the procedures in (A) or (B) above. The procedures are designed for the benefit of the exposed health care worker. The health care worker's signature for consent/refusal shall be obtained per Agency policy. IX. Medical Record Keeping: An accurate medical record for each health care worker with occupational exposure shall be established and maintained for the duration of employment plus thirty (30) years. This record shall include: q The name and social security number of the employee q A copy of the employee's Hepatitis B vaccination status including the dates of all Hepatitis B vaccinations and any medical records relative to the employee's ability to receive vaccination. q A copy of all results of examinations, medical testing and follow-up procedures. q The Agency's copy of the health care professional's written opinion. q A copy of the information provided to the health care professional. Confidentiality - The Agency shall ensure that the employee's medical records are kept confidential. Not disclosed or reported without the employee's express written consent to any person within or outside the workplace except as required by law. X. Quality Monitoring: The agency shall assess the health care worker's compliance with Universal Precautions and personal protective practices at least ANNUALLY. Home Health Agency Nursing Care & Procedures K-192